Overview
The below information is in regards to the base rate codes programs should use when billing Medicaid as well as the rates paid out based on those codes for providing any services covered under New York State Regulation Part 822. General Service Standards for Substance Use Disorder Outpatient Programs.
The downstate peer group includes New York County, Kings County, Queens County, Richmond County, Bronx County, Nassau, Suffolk, Westchester, Rockland, Putnam, Dutchess and Orange counties. The upstate peer group refers to the rest of New York State (ROS).
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Ambulatory Patient Group Manual
Rate codes, procedure codes and service description codes for both fee for service and managed care billing in Outpatient SUD, Opioid Treatment Programs and Integrated Services settings.
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APG Procedure Codes
Ambulatory Patient Group procedure codes and limitations for billing Medicaid fee-for-service.
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Coding Taxonomy
Coding Crosswalk including Rate Code, Procedure Code and Modifiers for Health and Recovery Plans (HARP) and Mainstream Behavioral Health Carve in Services
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Revenue Calculator
OASAS developed the APG Medicaid Revenue Calculator to simulate Medicaid revenue projections associated with APG pricing.
Certified outpatient programs may use the tool to continuously monitor and update their projected APG Medicaid revenues. The calculator has the base rates for the respective programs/peer groups; and, the application of the phased payments.
Outpatient Services
Ambulatory Patient Group (APG) and Federally Qualified Health Center (FQHC) base rates and reimbursement codes for certified outpatient clinics or outpatient rehabilitation programs.
Learn more and find guidance pertaining to outpatient Part 822 services, here.
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Peer Service Reimbursement Code Change
Letter to outpatient treatment providers outlining the transition for peer services from the Enhanced Rate Code to the Standard Rate Code
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Peer Service Reimbursement Code Change
Letter to Medicaid Managed Care plans regarding the transition of peer services from the Enhanced Rate Code to the Standard Rate Code.
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Opioid Treatment Programs
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APG Base Rates for Opioid Treatment Programs (OTPs)
Ambulatory Patient Group base rates for freestanding OASAS OTPs, hospital-based OTPs, and Article 28 providers.
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Dual Billing Guidance for Opioid Treatment Programs
Effective January 1, 2021, OTP providers billing services for individuals eligible for both Medicare and Medicaid should not bill Medicaid until a claim has been processed by Medicare.
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Hepatitis C Treatment Billing & Reimbursement
New York State guidance on reimbursement for HCV-related counseling, testing, and treatment services in OTPs and other programs with appropriate medical staffing.
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Comprehensive Outpatient Program (COP)
Comprehensive Outpatient Program (COP) is an integration of co-located 822 OTP and 822 Outpatient Treatment Services to provide services available in either program to all patients in each PRU (other than methadone).
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Comprehensive Outpatient Programs Overview Presentation
Learn more about COPs by reviewing this presentation.
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Comprehensive Outpatient Program Application Form
This application should only be completed by providers who have consulted with OASAS ATAR Division and Regional Office on Integrating 822 programs and becoming a Comprehensive Outpatient Program provider. For programs who have not, please contact your Regional Office Program Manager for more information.
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May 28, 2024 Notification to Managed Care Plans
On May 28, 2024, plans received this memorandum regarding the New York State Office of Addiction Support Services (OASAS) implementation of Comprehensive Outpatient Treatment Programs (COP). Please review the memorandum for a brief overview of the COP initiative.
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June 18, 2024 Notification to Managed Care Plans
On June 18, 2024, plans received a status update on the COP and the list of the programs that will be a COP along with a spreadsheet of the Comprehensive Outpatient Program List with effective dates.
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Comprehensive Outpatient Program List
Review the list of over 25 Comprehensive Outpatient Programs, including their legal name, provider number, reporting unit number, address and effective date.
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Integrated Care Licensure Threshold Guidance
The following guidance outlines changes in the licensure thresholds that permit certain providers to offer comprehensive ambulatory services, in accordance with New York States scope of practice laws and rules. These providers include DOH licensed Article 28 primary care providers, OMH licensed Article 31 Mental Health Outpatient Treatment and Rehabilitative Service (MHOTRS) providers, OASAS licensed Article 32 addiction outpatient treatment providers, and OPWDD licensed Article 16 intellectual and developmental disability (I/DD) service providers. For complete details, please refer to the NYS DOH Updated Licensure Threshold Guidance.
Medication Billing
Guidance on billing Sublocade intramuscular injection and oral buprenorphine in ambulatory settings), as well as billing for Vivitrol for outpatient programs.
Please note that changes to Chapters 69 and 71 of the Insurance Laws of 2016 prohibit prior Insurance authorization for medications for treatment of substance use disorder.
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Buprenorphine Billing
Information on billing for buprenorphine in outpatient clinic or rehabilitation settings and in opioid treatment programs (OTPs).
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Billing for Medication Management
An OASAS and Office of Mental Health memo on billing medication management for co-occurring disorders.
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Commercial Billing (Part AA of Chapter 57) Guidance
This section is for commercial health insurers and OASAS-certified substance use disorder providers. It provides guidance on complying with laws related to commercial reimbursement and billing for OASAS-certified ambulatory programs.
Part AA of Chapter 57 of the Laws of 2024 updated the Insurance Law to require insurance companies to pay certain in-network facilities that offer outpatient mental health and substance use disorder treatment. These payments must be at negotiated rates that are at least as high as what would be paid under the Medicaid program.
Chapter 57 requires that insurers must reimburse covered outpatient treatment provided by OASAS-certified providers.
Provider Types
- Outpatient Clinic Providers* – Both hospital and freestanding, reimbursed under Ambulatory Patient Groups (“APGs”).
- Outpatient Rehabilitation Providers* (aka OP Addiction Day Rehab) – Both hospital and freestanding, reimbursed under APG.
- Opioid Treatment Program* (“OTP”), including mobile medication services delivered by a mobile medication unit and Comprehensive Outpatient Program* (“COP”) providers– both hospital and freestanding, reimbursed under APGs including the weekly bundled rate.
- Mobile Crisis Intervention Services providers.*
- Crisis Stabilization Centers licensed pursuant to Mental Hygiene Law § 36.01.
* Please note all facility types listed above with (*) may provide services in the community.
Commercial Billing Resources
The following resources can be used to support commercial insurers and substance use providers with systems configurations needed for the implementation of Part AA, effective on or after January 1, 2025.
OASAS Ambulatory Provider Level Fee Schedule
This Excel file contains provider-specific Ambulatory Provider Group base rates with associated rate codes.
APG Outpatient Rate List
This Excel document contains fee schedules for OASAS outpatient services applicable to Part AA that are priced using the Ambulatory Provider Group methodology. It includes applicable rate codes.
Upcoming Webinars/Trainings
Check back soon for upcoming webinars/training sessions.
Office of Mental Health Website
Visit the Office of Mental Health Commercial Billing for Behavioral Health Services webpage for reimbursement rates for OMH ambulatory programs.
Contact Practice Innovation & Care Management Unit
If you have any questions, contact the Division of Practice Innovation and Care Management (PICM).